HomeMy WebLinkAboutReso 1986-12705 RESOLUTION NO. 12705
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CHULA
VISTA APPROVING AGREEMENTS TO IMPLEMENT TWO PREPAID
DENTAL PLANS FOR CITY EMPLOYEES AND THEIR FAMILIES FROM
BLUE CROSS (DENTAL NET) AND DELTA DENTAL (PMI DENTAL)
AND AUTHORIZING THE MAYOR TO EXECUTE SAID AGREEMENTS
The City Council of the City of Chula Vista does hereby
resolve as follows:
NOW, THEREFORE, BE IT RESOLVED by the City Council of
the City of Chula Vista that those certain agreements between THE
CITY OF CHULA VISTA, a municipal corporation, and Blue Cross
(Dental Net) and Delta Dental (PMI Dental) to implement two
prepaid dental plans for City employees and their families, dated
the 10th day of September , 1986 , copies of which are
attached hereto and incorporated herein, the same as though fully
set forth herein be, and the same are hereby approved.
BE IT FURTHER RESOLVED that the Mayor of the City of
Chula Vista be, and he is hereby authorized and directed to
execute said agreements for and on behalf of the City of Chula
Vista.
Presented by Approved as to form by
Candy Bd3~hell, Acting ~n0mas /~ , Y
Director of Personnel Attorney [/ ,
1958a
ADOPTED AND APPROVED BY THE CITY COUNCIL OF' THE CITY OF
CHULA VISTA, CALIFORNIA, this lOth day of September
19 86 , by the following vote, to-wit:
AYES: Councilmembers McCandliss, Campbell, Moore, Cox
NAYES: Counci 1 members None
ABSTAIN: Counci lmembers None
ABSENT: Counci lmembers Malcolm
Mayor CIt~ ~f Vista
STATE OF CALIFORNIA )
COUNTY OF SAN DIEGO ) ss.
CITY OF CHULA VISTA
I, JENNIE M. FULASZ, CMC, CITY CLERK of the City of Chula Vista, California,
DO HEREBY CERTIFY that the above ond foregoing is a full, true and correct copy of
RESOLUT[0N NO. 12705
,and that the some hos not been amended or repealed
DATED
City Clerk
CH VIMA
CC-660
Blue Cross APPLICATION FOR
GROUP SERVICE AGREEMENT(S)
Please prepare and sign two original copies of this form and return them with the membership enrollment forms.
Application is hereby made for: together with the reports necessary to maintain accurate and
complete membership records. Furthermore, applicant agrees
A Blue Cross of California Group Service Agreement to comply with the applicable regulations pertaining to mem-
bership requirements, additions to and deletions from the group.
the provisions of which are to be made available to alt eligible
employees, as defined below, and their eligible dependents Applicant shall inform alt eligible employees at the time of their
desiring coverage thereunder, employment that they may apply for Blue Cross membership
Applicant, m the event this application is accepted, agrees to after a probationary period of 0
make authorized payroll dues deductions for such eligible em- month(s) during which a person must be continuously em-
ployees who enroll under the agreement(s) and to forward such ployed by applicant.
amounts in advance of the due date to Blue Cross of California
The following information regarding employee personnel data is submitted to allow Blue Cross of California
to determine the eligibility of employees seeking enrollment hereunder.
Total Employees 698
150 part-time
Total Ineligible Employees
Total Eligible Employees 548 full-time
Definition of Eligible Categories: [~5] Permanent {~ Full-Time
[~ Working more than Jd hrs. per week [] Other Pormanorlt Part-time
20
Definition of Ineligible Categories: [] Temporary [] Part-Time
[] Working less than 30 hrs. per week [] Otber
100 ,, 0
Amount of Employer Contribution: (Fl=^ Plal'* ur P:yr u~°'[ Dependents: %
Authorized Broker of Record N/A Deduction) Broker N/A
Number
(IF APPI ICAgLE)
Applicant understands and agrees that:
FOR BLUE CROSS COVERAGE: (1) any new employee who does not enroll within THIRTY (30) days
following date of completion of a probationary period, if any; (2) current employees who do not enroll at
the original enrollment and (3) dependents who do not enroll when they first become eligible, may only
apply for coverage at the next enrollment period by furnishing evidence of insurability satisfactory to Blue
Cross uf California.
Dated this lOth day of SepLember , 19 86
Corporate Name City of Chula Vista
PIEASb((>MI'II!TEAII OFFHE Type of Business Municipality
ABOVE INFORMArION BEEORE
SIGNING AGRIEMENT PI_EASE County_San Di~ ~'~
Signature .
/1 ;//
Title Mayor
FOR BLUE CROSS USE ONLY Enrollment: Rejected [~ Accepted []
Coverage Etfective: By: Date
DENTAL HEALTH PLAN
Affiliated with Delta Dental Plan
DENTAL HEALTH CARE AGREEMENT
(Prepaid Plan)
THIS AGREEMENT is made and entered into this lOth day of September~ 198 6 , by and
between PRIVATE MEDICAL-CARE, INC. (hereinafter referred to as ~-~-~I") an-~-d CITY OF
CHULA VISTA, PMI GROUP #0767, (hereinafter called "Group") is made with reference
to the following facts:
WITNESSETH
A. PMI is a California Corporation, organized to operate a health care service
plan, registered under the California Knox-Keene Health Plan Act, to provide
various individuals and groups with health care benefits.
B. Group represents that it has a bona fide list of members and is authorized to
enter into agreements for dental care services on their behalf.
C. The parties desire by this Agreement to establish a dental care program for
the benefit of the members of the Group, covering the following services:
NOW, THEREFORE, in consideration of the mutual covenants herein contained and for
other good and valuable consideration, it is agreed as follows:
1. Term
The terms of this agreement shall be from October 1, 1986, through
September 30, 1987 and shall automatically be renewed for additional
successive one-year terms unless either party shall give written notice of
termination to the other party at least thirty (30) days prior to the end of
any such yearly term in which event this Agreement shall be terminated at the
end of such yearly term.
1.I
PMI shall not increase the monthly membership fees paid by Group, nor decrease
in any manner the benefits stated in this Contract, except after a period of
at least thirty (30) days from and after a postage-paid mailing to Group, at
Group's address of record with PMI of written notice of such proposed change.
Any such change shall become effective on the anniversary date of this
Contract next succeeding the expiration of said notice period, unless a
different effective date is agreed to by the parties.
5122 Kat¢lla Avenue, Suite 206, Los Alamitos, CA 90720 (213) 493 6661, (714) 978-6624
So California [ 800 325-4529 No Californm 1-800-422 4234 Nationwide 1 800-821-2058
1.2
If this contract is renewed as provided above, the coverage of each person is
automatically renewed; if the contract is not renewed, coverage of all
eligible persons ceases on the date the contract terminates. A subscriber may
reinstate his membership in PMI after having previously allowed eligibility to
lapse so long as this contract remains in effect for the Group. A subscriber
must pay all unpaid monthly fees from the time eligibility lapsed up to and
including the current payment before he may be reinstated.
1.3
PMI shall not cancel or decline to renew or reinstate the contract, nor modify
its terms, nor shall the benefits or coverage be subject to any limitations,
exceptions, exclusions, reductions, copayments, co-insurance, deductibles,
reservations, or membership fees, price or charge differential, because of
race, color, national origin, ancestry, religion, sex, marital status, sexual
orientation or age of any member of Group or any person reasonably expected to
benefit from this Contract as a subscriber, enrollee, member or otherwise.
2. Group shall provide a list of eligible subscribers each month commencing
October 1, 1986. PMI promises to Group, to provide, during the term of this
Agreement, to each subscriber whose name appears on the eligible list, and
each other eligible person in his family as defined in paragraph 3 below,
commencing on the first day of the month as to which the subscriber's name so
appears, and continuing so long as the subscriber's name continues to appear
on such eligible list (but in no event beyond the term of this Agreement), and
so long as the fees are paid with respect to such subscriber as provided in
paragraph 4 below, the services described in Schedule A attached, subject to
the limitations and exclusions described in Schedule B attached. PMI may
require eligible persons to present, prior to receiving any such services,
reasonable proof of eligibility in accordance with uniform procedures to be
established by PMI from time to time.
2.1
Each subscriber of Group will have a minimum enrollment requirement of one (1)
year. Should a subscriber voluntarily terminate coverage prior to the one (1)
year minimum requirement and subsequently desire to re-enroll, subscriber
would be responsible for payment of all premiums retroactive to date of
voluntary termination (not to exceed twelve (12) months) prior to
reinstatement into the plan. This would not apply to Group layoff or
termination.
2.2
All benefits and services described in Schedule A shall cease as to a given
subscriber, and other eligible persons in his family, at the end of the last
pay period for which payment is made by Group as provided in paragraph 4
below, with respect to each subscriber, except as provided in paragraph 2.3.
AG25.0767 2
2.3
In the event the Group ceases to exist or this Contract is terminated, or a
subscriber leaves the Group, or otherwise ceases to be eligible for coverage,
the subscriber nonetheless may continue his eligibility in the plan if he or a
family member is then in the process of receiving dental services pursuant to
this Contract, until such services are completed, provided that: (a) during
such period the subscriber must maintain current payments of membership fees;
and (b) no new or additional work may be started during this temporary
membership.
2.4
If an eligible person is outside of the geographical area served by PMI more
than 35 miles from the office of the participating doctor then utilized by the
eligible person, and requires emergency dental care, then PMI shall reimburse
the eligible person for the cost of such treatment up to a maximum of $50.00,
during each 12 calendar month period, less any applicable copayments, upon
presentation to PMI within ninety (90) days after such treatment is received
and verifiable bill therefore.
2.5
If an eligible person's coverage terminates and the eligible person is not
covered under any other Dental Plan or Group, the eligible person is
automatically eligible to receive dental services at a cost to eligible person
not in excess of the PMI Guaranteed Fee Schedule that is currently in effect
at the time of service. The eligible person is eligible to receive services
according to this Fee Schedule for a period of one year after termination and
only when services are rendered by a participating doctor. This Fee Schedule
shall be available from PMI upon request.
3. Definition of Eligible Persons
Eligible persons shall include all members of Group, and the spouses (unless
legally separated or divorced) and unmarried dependent children under nineteen
(19) years of age, of such members. Unmarried children who are 19 years of
age or older, but less than 23 years of age, will also be considered as
eligible persons if they are enrolled on a full-time basis (at least 12 units
per quarter or semester) as a student in an accredited school or college and
are wholly dependent upon the subscriber for maintenance and support.
Provided, however, that a dependent child shall remain eligible despite
attaining such limiting age while the child is and continues to be both (a)
incapable of self-sustaining employment by reason of mental retardation or
physical handicap, and (b) chiefly dependent upon the subscriber for support
and maintenance, provided proof of such incapacity and dependency is furnished
to PMI by the subscriber within thirty-one (31) days of the child's attainment
of the limiting age and subsequently as may be required by PMI but not more
frequently than annually after the two-year period following the child's
attainment of the limiting age. The word "child" includes a lawfully adopted
child, and any stepchild or foster child who depends on the subscriber for
maintenance and support and has the same permanent residence as the
subscriber. Dependents in the military service are not eligible.
AG25.0767 3
4. Fees
The monthly fees payable to PMI hereunder shall be $8.93 per member only,
$14.77 per member plus one dependent and $21.75 per member plus two or more
dependents. Group agrees to collect said fees by means of payroll deduction
for all employees and/or all eligible dependents voluntarily enrolling in the
plan. Group also agrees to remit one check monthly for premium payment of all
group subscribers. Such fees shall be mailed to PMI at 5122 Katella Avenue
#206, Los Alamitos, California 90720. In addition to these membership fees,
subscribers and eligible dependents are required to pay any copayments listed
in this Agreement directly to the participating doctor. If subscriber or
eligible person voluntarily terminates his benefits hereunder, he is required
to pay the participating doctor for all services thereafter provided in an
amount equal to the then current, usual, customary and reasonable fee of the
participating doctor. Subscribers and eligible dependents will be charged
$10.00 for each broken appointment (unless notice is received by the
participating doctor at least 24 hours in advance) and $20.00 for each
emergency visit after normal visiting hours.
5. Participating Doctors
The services provided for by this Agreement shall be rendered by participating
Doctors and PMI shall have no obligation or liability to eligible persons with
respect to services rendered to them by non-participating doctors, with the
exception of the "out of area emergency services" as provided in paragraph 2.3
and a specialist to whom your PMI Panel Dentist has referred you, and said
specialist has been authorized in writing by PMI. All approved specialty care
claims will be paid by PMI less the patients copayments (if any) and excluded
services such as general anesthesia. A list of participating doctors shall be
furnished to all subscribers and notices of revisions of such list will be
mailed to subscribers periodically, or furnished to them on request. All
services will be rendered at the office of the participating doctor. It is
understood that any participating doctor may provide services to eligible
persons either personally, or through associated doctors, or the other
technicians, personnel or employees as may lawfully perform the particular
service required. PMI agrees to provide participating doctors during the term
of this Agreement at convenient locations mutually acceptable to Group.
5.1
The subscriber may select any participating doctor whose name is contained in
said list at the time his eligibility begins, and may make a change to any
other such participating doctor during the thirty (30) day period before the
renewal date of this Agreement. Any other change requested by a subscriber
will be made upon thirty (30) days written notice given by the subscriber to
PMI and a showing by him of conflict between himself and the doctor previously
selected.
5.2
PMI shall provide written notice within a reasonable time to Group of any
termination or breach of contract by, or inability to perform, of any
participating doctors if Group may be materially and adversely affected
thereby.
AG25.0767 4
5.3
In the event PMI fails to pay a participating doctor, the eligible person
shall not be liable to the participating doctor for any sums owed by PMI. In
the event PMI fails to pay a non-participating doctor, the eligible person may
be liable to the non-participating doctor for the cost of services.
5.4
Upon termination of a contract between PMI and a participating doctor, PMI
shall be liable for covered services rendered by such doctor (other than for
copayments as set forth in the Schedule of Benefits) to a subscriber or
enrollee who retained eligibility under this Contract or by operation of law
under the care of such doctor at the time of such termination until the
services being rendered to the subscriber or enrollee by such doctor are
completed, unless PM1 makes reasonable and medically appropriate provisions
for the assumption of such services by another participating doctor.
6. Disputes
Any dispute or controversy arising out of or relating to this Agreement, shall
be resolved by arbitration as follows: Either party to the dispute (if one of
the parties is an eligible person, Group, at its option, may act on behalf of
such person; if one of the parties is a participating doctor, PMI, at its
option, may act on behalf of such doctor) may commence the arbitration
proceeding at any time within six {6) months after the dispute arises by
written notice to the other party selecting and naming an arbitrator. Within
thirty (30) days after receipt of such notice, the other party shall select
and name an arbitrator and so advise the initiating party in writing. The two
persons so selected shall proceed to name a third neutral arbitrator within
sixty (60) days after notice of appointment of the second arbitrator.
The Board of Arbitration shall proceed with all possible dispatch to hear and
determine the dispute. It shall require the affirmative vote of two of the
three members of the Board to decide the issue, and the decision in all cases
shall be binding upon the parties hereto. The decision shall be in writing
and signed by all members of the Board but shall be legal and binding when
signed by a majority thereof. Each party shall bear the fees and expenses of
the arbitrator approved by that party. The expenses of the third or impartial
arbitrator, who shall be Chairman of the Board, and stenographic expenses
shall be borne equally by the parties to the dispute. The Board of
Arbitration shall have no power to add to, subtract from, modify, or make any
changes as to the terms of this Agreement. In the event the two arbitrators
fail to select a third neutral arbitrator within the sixty (60) day period
prescribed above, or if the parties to the dispute so agree, the matter shall
instead be submitted to arbitration before the American Arbitration
Association in accordance with its then prevailing rules, in which case the
decision of the arbitrator shall be binding on the parties. In the event that
suit is instituted to enforce any of the provisions of this Agreement, or the
Arbitration award, the prevailing party shall be entitled to recover, in
addition to any other relief which may be awarded, its reasonable attorney's
fees in connection therewith.
AG25.0767 5
7. Definitions
As used in this Agreement, the following terms shall have the following
meanings:
a. "Enrollee" or "Eligible person" means a person who is enrolled with PMI,
and who is a recipient of services from PMI.
b. "Co-payment" means an additional fee charged to an eligible person which
is approved by the Commissioner of Corporations, provided in this
Contract, and disclosed in the Evidence of Coverage.
c. "Evidence of Coverage" means any certificate, agreement, contract,
brochure, or letter of entitlement issued to a subscriber or eligible
person setting forth the coverage to which the eligible person is
entitled.
d. A factor is "material" with respect to a matter if it is one to which a
reasonable person would attach importance in determining the action to be
taken on the matter.
e. "Act" means the Knox-Keene Health Care Service Plan Act of 1975, or any
successor thereto under which PMI is regulated.
f. "Subscriber" means a person who is responsible for payment to PMI or
whose employment or other status, except for family dependency, is the
basis for eligibility.
g. "Participating Doctor" means a doctor with whom PMI has an agreement to
provide services to eligible persons hereunder.
h. "Benefits" and "Coverage" means the health care services available under
this Contract.
8. Cancellation
Enrollment of a subscriber or eligible person under this Agreement may be
cancelled, or renewal refused by PMI only in the following events
(cancellation of enrollment of a subscriber shall automatically cancel the
enrollment of all other eligible persons in his family as defined in
paragraph 3):
a. Upon expiration or termination of this Group Contract, if it is not
renewed.
b. Upon person's ceasing to come within the definition of "eligible persons"
as set forth in paragraph 3 above.
c. If the membership fees are not paid by or for the eligible person within
fifteen (15) days.
AG25.0767 6
d. On thirty (30) days written notice, such cancellation to be effective at
the end of the notice period:
1) If the subscriber is dropped by the Group from the eligible list, or
ceases to be a member of Group.
2) If the subscriber fails to make payments of copayments or other
charges required of him or an eligible member of his family
hereunder; provided, however, that the subscriber may be reinstated
during the term of this Agreement upon payment of said delinquent
charges or copayments and any unpaid monthly membership fees.
3) If the subscriber or eligible person is guilty of habitual
intemperance or misconduct while in the office of a participating
doctor.
4) If the subscriber or eligible member of his family knowingly
perpetrates or permits another person to perpetrate, fraud, or
deception in the use of the services of facilities of or provided by
PMI.
e. A subscriber or eligible person who alleges that his enrollment or
subscription has been canceled or not renewed because of the enrollee's
health status or requirements for health care services may request a
review by the Commissioner of Corporations. If the Commissioner
determines that a proper complaint exists under the provisions of Section
1365 of the Health and Safety Code, the Commissioner shall notify PMI.
Within fifteen (15) days after receipt of such notice, PMI shall either
request a hearing or reinstate the subscriber or eligible person. If,
after hearing, the Commissioner determines that the cancellation or
failure to renew is contrary to subdivision (b) of Section 1365 shall be
retroactive to the time of cancellation or failure to renew and PMI shall
be liable for the expenses incurred by the subscriber or eligible person
for covered health care services from the date of cancellation or
non-renewal to and including the date of reinstatement.
f. In the event of cancellation by PMI (except in the case of fraud or
deception in the use of services or facilities of PMI or knowingly
permitting such fraud of deception by another) or by Group, PMI shall
within thirty (30) days return to Group the pro rata portion of the money
paid to PMI which corresponds to any unexpired period for which payment
had been received, together with any amounts due on claims, if any, less
any amounts due to PMI.
g. Acceptance by PMI of the proper monthly membership fees, after
termination of the Contract and without requiring a new application,
shall reinstate the Contract as though it had never terminated, unless
PMI shall within five (5) business days of receipt of such payment,
either (1) refuse the payments so made, or (2) issue to Group, a new
Contract accompanied by written notice stating clearly those respects in
which the new Contract differs from the terminated Contract in benefits,
coverage or otherwise.
AG25.0767 7
9. California Health & Safety Code
PMI is subject to the requirements of Chapter 2.2 of Division 2 of the
California Health & Safety Code (the "Act") and of Subchapter 5.5 of Chapter 3
of Title 10 of the California Administrative Code (the "Regulations"), and any
provisions required to be in this Contract by either of the above shall bind
PMI whether or not provided in this Contract.
10. Group Representative
Group shall designate in writing a representative for purposes of receiving
notices from PMI under this Contract. Group may change its representative at
any time on thirty (30) days written notice to PMI. Any notice required from
PMI to either Group or any eligible person may be given by PMI to the Group
representative, who shall disseminate such notice to subscribers and enrollees
from Group by next regular communication to such subscribers and enrollees but
in no event later than thirty (30) days after receipt thereof. The initial
group representative for purposes of this Contract shall be Diana Levin, Risk
Manager.
11. Written proof of loss must be furnished to PMI, in case of claim for any loss,
within ninety (90) days after the date of such loss. Failure to furnish such
proof within the time required shall not invalidate nor reduce any claim if it
is not reasonably possible and in no event later than one (1) year from the
time proof is otherwise required.
IN WITNESS WHEREOF, the parties have executed this Agreement and have affixed their
signatures on the 10th day of September , 1986~.
CITY OF CHULA VISTA PRIVATE MEDICAL-CARE, INC.
GR UP 0767
Signatu¥~.,£ !~ ' Date S~nature ~nd ~it~e~' e
(Print) Name and Title
276 Fourth Avenue
Address
Chula Vista CA 92010
City State Zip
61g/691-5096
Telephone Number Rev. 1/3/86
AG25.0767 8
SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS
These services are performed as needed and deemed necessary by your attending PMI
Panel Dentist subject to the exclusions, limitations and governing administrative
procedures of the plan.
MEMBER
VISITS AND DIAGNOSTIC PAYS
Oral examination/Office visit ............................ No Cost
Emergency treatment, palliative ................... $ 5.00
Specialist consultation ............................... No Cost
No Cost
Vitality tests .......................................
PROPHYLAXIS AND FLUORIDE TREATMENTS
Prophylaxis - 2 treatments per any 12 month period .......... No Cost
Topical Fluoride - to age 18 only ....................... No Cost
ROENTGENOLOGY
Full mouth x-rays or Panorex - every 2 years ................ No Cost
No Cost
Single x-ray .................... ";"J'""'":~'~iir~'~]]]]']] No Cost
Each additional x-ray - up to ano lnc/uolng ~J ·
Bite-wing x-rays - not more than I series of 4 films in any
six month period .......................................... No Cost
Intra-oral, occlusal view, maxillary or mandibular .......... No Cost
ORAL SURGERY
Extractions (uncomplicated) - local anesthetic .............. No Cost
No Cost
Surgical extractions ..............
Post operative visits'i~J~i'~].]]]]]]]]'] ....... ]]]] ..... No Cost
Impacted teeth
Removal of tooth (soft tissue) ......................... No Cost
Removal of tooth (partially bony) ........ ]]]]]]]]] $ 50.00
Removal of tooth (completely bony) .] ...... ]]]] $ 70.00
No Cost
Biopsy of oral tissues - --
$ 40.00
Alveolectomy edentulous, per quadrant ....................
$ 60. O0
Alveolectomy and ridge extension, per arch ...............
No Cost
Palatal torus ............................................
No Cost
Mandibular torus ....
No Cost
Frenectomy ...............................................
No Cost
Local anesthetics ................. ~Ai,~'2AJ'GA ~ ...........
General anesthesia for extractions 1
when medically necessary .................................. $ 35.00
MEMBER
PERIODONTICS PAYS
Emergency treatment (periodontal ~bscess,
acute periodontitis, etc.) ........ $ 5.00
Subgingival curettage, root planing~'~'~adr~']~]]]]i]~ $ 10.00
Gingivectomy, per quadrant .................................. $100.00
Gingivectomy, per tooth (if fewer than 6 teeth) ............. $ 20.00
Osseous or muco-gingival surgery, per quadrant .............. $200.00
ENDODONTICS
..... No Cost
Pulp capping ..........................................
Pulpotomy ............................ No Cost
Vital pulpotomy ........................................... No Cost
Temporary filling with CaOH ............................... No Cost
Culture canal ............................................ No Cost
Root canal therapy (per canal)..] .......................... $ 45.00
..... No Cost
Root amputation ......................................
Apicoectomy and filling canal ............................. $ 75.00
Apicoectomy on separate appointment ........................ $ 50.00
RESTORATIVE DENTISTRY
Amalgam Restorations Primary Teeth
No Cost
Cavities involving one tooth surface ·
Cavities involving two tooth surfaces ..................... No Cost
Cavities involving three or more tooth surfaces ........... No Cost
Amalgam Restorations Permanent Teeth
Cavities involving one tooth surface ...................... No Cost
Cavities involving two tooth surfaces ..................... No Cost
Cavities involving three or more tooth surfaces ........... No Cost
Silicate, Acrylic, Plastic Restorations
Silicate cement filling.............. .................. ... No Cost
Acrylic or plastic filling ................................ No Cost
Pin build-up ............................................... $ 10.00
Crowns
Acrylic ....... $ 50.00
Acrylic with metal ....................................... $ 85.00
Porcelain . $ 85 O0
Porcelain with metal .................................... $ 85.00
Full metal crown* ....................................... $ 85.00
Gold onlay or 3/4 crown* . $ 85 O0
Stainless steel (primary) ............................... No Cost
Stainless steel (permanent) ............................. No Cost
10
MEMBER
PAYS
Removable acrylic space maintainer .......................... $ 20.00
$ 2o.oo
Fixed Spacer, band type ..................................... $ 10 O0
Dowel post .................... $ 10 O0
Pin build up ................................
PROSTHETICS (includes Fixed Bridges)
Pontics:
$ 85.00
Tru-pontic type ........................................... $ 85 O0
Porcelain to metal · '
Plastic processed to gold* ............... $ 85.00
Dentures:
Maxillary denture ....... $100.00
$100.00
Mandibular denture 'i~i']]~]]] ......... i]]]]]i]']]]i~]]i
Partial upper/lower .......... $115.00
Stress breakers, per unit ................................. No Cost
Teeth and clasps per unit . No Cost
Denture duplication ......................................... $ 50.00
$ 10.00
Denture and partial adjustments ............................
· $ 20 O0
Denture and partial repairs .....................
Adding teeth to existing partial or denture .... ].]]]]]i]]]]] $ 10.00
$ 20.00
Office reline ............................................... $ 40 O0
Laboratory reline ..................................... Cost
...... No
Tissue conditioning, 2 per denture ..................
Recementation
No Cost
Inlay . · ~
Crown ~.~i~.~l~~]i]~i~ ~ No Cost
Bridge .................................................... No Cost
ORTHODONTIA (excluding start-up fees)
$1400.00
Full banded case ..........................................
Failure to cancel appointment (24 hour prior notification) .. $ 10.00
Emergency visit after normal visiting hours ................. $ 20.00
Any procedure not listed is available on a fee-for-service basis.
* Plus actual lab cost of Precious Metals.
11
SCHEDULE B
LIMITATION OF BENEFITS
The benefits, as outlined, are subject to the following limitations:
1. Prophylaxis limited to 2 treatments in any 12 consecutive months.
2. Full upper and/or lower dentures are not to exceed one each in any 3 year
period. Replacement will be provided by PMI for an existing denture or bridge
only if it is unsatisfactory and cannot be made satisfactory.
3. Partial dentures are not to be replaced within any 3 year period unless
necessary due to natural tooth loss where the addition or replacement of teeth
to the existing partial is not feasible.
4. Fixed bridges will be authorized ONLY when a partial cannot satisfactorily
restore the case. If fixed bridges are used when a partial could
satisfactorily restore the case, it is considered optional treatment. You
would pay the difference between the cost of a partial and a fixed bridge.
5. Denture relines limited to one during any 12 consecutive months.
6. Periodontal treatments limited to five during any 12 consecutive months.
7. Bite-wing x-rays limited to not more than one series of 4 films in any six
month period.
8. Full mouth x-rays limited to one set every 24 consecutive months.
9. General anesthesia and the services of a special anesthesiologist, except for
extractions only and only when medically necessary.
EXCLUSION OF BENEFITS
1. Cosmetic dental care.
2. Dental conditions arising out of and due to members employment or for which
Workers' Compensation is payable.
3. Treatment required by reason of war.
4. Hospital charges of any kind.
5. Major surgery of fractures and dislocations.
6. Loss or theft of dentures or bridgework.
7. Lost, stolen or broken orthodontic appliance.
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8. Whenever charges for covered dental expenses are covered by another Group,
franchise, or group service plan or insurance or pre-payment plan, the
following order of benefits determination established the sequence of payment:
a. If the other coverage does not contain a non-duplication provision, that
plan must pay for its benefits before coverage is afforded hereunder;
b. If the other coverage contains a non-duplication or coordination of
benefits provision:
1) The plan covering the individual as the member pays before the
program covering the individual as a dependent.
2) Where the order of payment cannot be determined in accordance with
these rules, the first plan to make payment will be the one who has
covered the insured for the longer period of time. The plan that
pays first calculates benefits exactly as through dual coverage did
not exist.
3) Any payment received by the Panel Dentist from other coverage will
be applied to any copayments due the Panel Provider from the member.
9. Services which are provided to the member by state government or agency
thereof, or are provided without cost to the member by any municipality,
county or other subdivisions.
10. Dental expenses incurred in connection with any dental procedure started after
termination of eligibility for coverage.
11. Any service that is not specifically listed as a covered expense.
12. Dental expenses incurred in connection with any dental procedure started prior
to member's eligibility with PMI. Example: teeth prepped for crowns, root
canals in progress.
13. Congenital malformations.
14. Malignancies.
15. Dispensing of drugs not normally supplied in a dental office.
16. Any dental procedure unable to be performed in the dental office because of
the general health and physical limits of the member. Conditions which might
prevent utilization of PMI dental benefits would include physical or emotional
resistance or allergy to all commonly utilized local anesthetics; extremely
contagious diseases which might endanger the staff and patients of a typical
general dentistry office and severe medical problems which would make dental
therapy at a typical general dentistry office unwise.
17. Those procedures which are necessary for complete oral rehabilitation or
reconstruction.
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GOVERNING ADMINISTRATIVE POLICIES
Unlike medical care where the diagnosis dictates more specifically the method of
treatment to be rendered, in dental care, the dentist and his patient frequently
consider possible special optional treatment plans.
The followin§ "administrative guidelines" are an integral part of the dental
pro§ram and are consistent with the principles of accepted dental practice and the
continued maintenance of good dental health.
1. OPTIONAL TREATMENT
In all cases in which the patient selects a more expensive plan of treatment
than is customarily provided, PMI will allow the applicable fee for the
treatment customarily provided. The patient must pay the entire remainder of
the dentist's fee. For example:
a. Partial Dentures: If a cast chrome or acrylic denture will restore the
case, the panel dentist will allow the applicable percentage of the cost
of such procedure toward a more complicated precision appliance that the
patient and dentist may choose to use.
b. Complete Dentures: If, in the construction of a denture, the patient and
dentist decide on personalized restorations or employ specialized
techniques as opposed to standard procedures, the panel dentist will
allow the applicable percentage of the cost for the standard denture
toward such treatment and the patient must bear the difference in cost.
c. Reconstruction: The panel dentist will allow the cost of procedures
necessary to eliminate oral disease and to replace missing teeth.
Appliances or restorations necessary to increase vertical dimension or
restore the occlusion are considered optional and the cost is the
responsibility of the patient.
d. Specialized Techniques: Precious metal for removable appliances,
precision abutments for partials or bridges (overlays, implants, and
appliances associated therewith), personalization and characterization,
all are considered optional treatment. Patient should be advised of
additional fee.
e. Implants: If implants are utilized, PMI will make payment of the cost of
a standard full or partial denture toward the cost of implants and
appliances constructed thereon. PMI will not provide surgical removal of
implants.
f. Fixed Bridges will be used ONLY when a partial can not satisfactorily
restore the case. Fixed bridges should not be used when abutment teeth
are perfectly healthy and would be crowned only for the purpose of
supporting a pontic. If fixed bridges are used under these
circumstances, it is considered optional. Allowance will be made for
partial. Patient must pay additional fee.
AG25.0767 14
2. COMPLETE DENTURES
The patient is entitled to a new upper or lower denture only if his own
existing denture cannot be made satisfactory by either reline or repair. Full
upper and/or lower dentures are not to exceed one each any 36 consecutive
months from the date they were first made under the plan.
3. PARTIALS (Removable)
If patient is missing teeth on opposite sides of the same arch, then a
removable partial is considered an adequate replacement. If patient elects
another course of treatment, the patient must pay the additional cost.
4. FILLINGS AND CROWNS
a. Crowns will be covered only if there is not enough retentive quality left
in tooth to hold a filling. (Example: Buccal or lingual walls either
fractured or decayed to extent that they do not hold a filling.)
b. Veneers, posterior to the second bicuspid, are considered purely cosmetic
dentistry. Allowance will be made for cast full crown. If performed,
patient must pay the additional fee.
c. PMI provides amalgam, synthetic or plastic restorations for treatment of
caries. If the tooth can be restored with such materials, any other
restoration (crown or jacket) is considered optional, and if performed,
patient must pay additional fee.
d. Composite resin or acrylic restorations in posterior teeth are optional.
Allowance will be made for amalgam restorations. If performed, patient
must pay additional fee.
e. Porcelain crowns, porcelain fused to metal or plastic processed to metal
type crowns are not a benefit for children under 12 years of age.
Allowance will be made for acrylic crown. If performed, patient must pay
additional fee.
f. A crown placed on a specific tooth is allowable only once in any three
year period except when the crown is no longer functional as determined
by the dentist.
5. FIXED BRIDGES
a. Fixed bridges will be covered only when a partial cannot satisfactorily
restore the case. Fixed bridges will not be used when abutment teeth are
healthy and would be crowned only for the purpose of supporting a pontic.
If fixed bridges are used under these circumstances, it is considered
optional. Allowance will be made for partial. Patient must pay
additional fee.
b. PMI will not allow for a posterior bridge in connection with a partial
denture in the same arch. If performed, patient must pay additional fee.
c. Fixed bridges are not a benefit for patients under the age of 16. If
fixed bridges are used under these circumstances, it is considered
AG25.0767 15
optional. Allowance will be made for space maintainer. If performed,
patient must pay additional fee.
6. MISCELLANEOUS
a. Preventive control programs including sealants, oral hygiene instruction
and dietary instruction are not covered benefits, therefore, are
considered optional benefits. If performed, patient will be charged the
doctor's usual and customary fee.
b. Under contractual provisions covering limitations, procedures,
appliances, or restorations {other than those for replacement of
structure loss from caries) that are necessary to alter, restore or
maintain occlusion, are not covered benefits and, if performed, patient
must pay additional fee. These include:
increasing vertical dimension.
replacing or stabilizing tooth structure loss by attrition.
realignment of teeth.
periodontal splinting.
gnathologic recordings.
equilibration, or
treatment of disturbances of the temporomandibular joint.
c. Stayplates are only a benefit to replace extracted anterior teeth for
adults during healing period and as anterior space maintainers for
children. Others are considered optional and, if performed, patient must
pay additional fee.
d. If patient desires to transfer from one panel dentist to another, and the
transfer is authorized by PMI for good reason, the transfer will take
effect on the first of the following month.
AG25.0767 16
SCHEDULE C
ORTHODONTIC LIMITATIONS AND EXCLUSIONS
The program provides coverage for orthodontic treatment plans provided through PMI
Panel Orthodontists. The maximum cost to the member for each treatment plan is
$1,400.00 plus start-up costs and subject to the following:
A. Orthodontic treatment is available ONLY for unmarried dependent children under
the age of 19.
B. Orthodontic treatment must be provided by a member of the PMI Orthodontic
Panel.
C. Plan benefits cover 24 months of usual and customary orthodontic treatment.
D. The following are not benefits included as orthodontia:
1. Cephalometric x-rays;
2. Tracings and photo§raphs;
3. Study Models;
4. Lost or broken appliances;
5. Retreatment of orthodontic cases;
6. Treatment in progress at inception of eligibility;
7. Changes in treatment necessitated by accident of any kind;
8. Surgical procedures (including extraction of teeth solely for the
purpose of orthodontia) incidental to orthodontic treatment;
9. Myofunctional therapy;
10. Surgical procedures related to cleft palate, micro§nathia or macro§nathia;
11. Treatment related to temporomandibular joint disturbances and/or hormonal
imbalance;
12. Dispensin§ of drugs not normally supplied in a dental practice;
13. General anesthetics including intravenous and inhalation sedation;
14. Dental services of any nature performed in a hospital;
15. Any dental procedures considered within the field of general dentistry
such as fillings or extractions;
16. Malocclusions which are so severe or mutilated so as not to be amenable to
ideal orthodontic therapy;
AG25.0767 17
17. Treatment that extends 24 months beyond the point of full permanent
dentition will be subject to an office visit charge.
E. Should a member be terminated for whatever reason and at the time of
termination be receiving any orthodontic treatment, the member and not PMI
will be responsible for payment of balance due for treatment performed after
termination. The member's payments shall be based on the maximum fee of
$1,400.00 and be pro-rated over the number of months to completion of the
treatment and be payable on such terms and conditions as are arranged between
the member and the orthodontist. In no event shall the member be liable for
more than the sum of $1,400.00 for the treatment plan {does not include
start-up fees).
F. Start-up fee shall consist of the initial examination, diagnosis and
consultation as well as study model impressions and the retention phase of
treatment of up to two years maximum. This includes initial construction,
placement and adjustments to retainers for a maximum period of two years.
This amount is $350.00 and is subject to review and change on an annual basis.
G. If treatment is not required or the member chooses not to start treatment
after the diagnosis and consultation has been completed by the provider, the
member will be charged a consultation fee of $25.00 in addition to diagnostic
record fees.
H. The European method of orthodontia -- activator appliances used in conjunction
with eventual banding -- is to be considered as full treatment.
I. Adults are not covered under the orthodontic program but may be covered for an
additional fee.
J. Should this contract be terminated by either party due to the breach or
non-renewal at the end of any applicable term, the provision of paragraph E
above shall apply with respect to a member being treated for orthodontic work
which is not completed at the date of termination.
AG25.0767 18